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INDEPENDENT SGHUUL. UM I MILL I tvv. cvc <br /> Community Services Department <br /> 3301 Silver Lake Rd a SL Anthony, MN 55418 • Phone: 781-5021 <br /> Facilities Reservation Form Permit No. <br /> Name Y7: ="'� T" � i Home Phone Bus. Phone <br /> Address".. 1f Date <br /> Name of,G�oiip.or Organization t �C�I�� 1 f S <br /> ^ . 1 Ar O r. - <br /> Intended Use. <br /> ^a ENO <br /> Date(s) wanted r11 �- Day(s) Su M T W T�t,Sa (circle) <br /> Building:;;:;_;;: <br /> Hig)i•School -Auditorium <br /> Par1i..View.Comm4nity Center f�__�j r i`! -f - Cafeteria <br /> 1A1i1shir�.Park Elem: chool T Cl4ssrod n(s) # ; <br /> Other <<( A f-t'ri Gymnasium (If High School, circle one: <br /> OLD NEW ) <br /> -- V. ��I C,- t U_ r` Kitchen <br /> 1�"�•ac �- —Other <br /> X <br /> Doorsto.open; m p r«l Expected attendance: <br /> �' �LtrJnr�fe� <br /> Activity begins am rr pm Admission: Free Charge <br /> Activity ends am pm Will merchandise be sold? <br /> Special arrangements needed (chairs, cooks, AV equipment, etc.): <br /> '74- <br /> It <br /> 1, % f- f7cf t `r L <br /> I hereby certify that I am an agent of the above named group or organization and am authorized to accept-`n their <br /> name the eesponsibility for observance of the rules and regulations of the Board of Education, I idependent chool <br />- - District 0282:As a group or organizational agent,l will attend this function,and I will be solely responsible fo giving <br /> instr t%s.to,tre custodianq or other support personnel.Presentation of this permit tithe custOdlan on <br /> dutyls necessa fo admittance G the )nittal�at In'accepting this arra'ngemgnt,.Tentee s _Fees tahold harmless: <br /> I.S.D. 282 and its representatives from all claims incurred in.use of-tbe•facility.Rentee waives all rights and claims for <br /> potential damages incurred in this rental arranQement. �., ,.• r :t_; ; ,�, rl. ;� . }� <br /> - � N <br /> `isighatule of responsible person) <br /> a <br /> Bill to: <br /> i (name) (address) <br />--------------------------------------------FOR OF FIQE USE <br /> � k—T LY-----------:-------------------- - —--------- <br /> Class Ins Approved by -`�6A ' f? i- Date <br /> Charges:*"Rental Custodial <br /> Cooks ` Other charges: <br /> Note: i it rJ:l I' ,: F( � ��' I {til � 1.��•`/� �!� �� .+ J <br /> AM1110 1%Y <br /> WHITE—Cwn�nuNly Siivk..Otoc•Copy CANARY—Budnese �opvr PIN Cu.lodl.m Copy O D—App ie.nr. y �: ` <br />